Journal of Surgical Case Reports, 2021;4, 1–3

doi: 10.1093/jscr/rjab153
Case Report

CASE REPORT

Strangulated Amyand’s hernia: management

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during the COVID-19 pandemic
Zeeshan Afzal* and Robert O’Neill
Cambridge Oesophago-gastric Centre, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation
Trust, Cambridge CB2 2QQ, UK
*Corresponding address: Cambridge Oesophago-gastric Centre, Addenbrookes Hospital, Cambridge University Hospital NHS Foundation Trust, Hills Road,
Cambridge CB2 2QQ, UK. Tel: +44 (0) 7741651215; E-mail: zeeshan.afzal@nhs.net

Abstract
Amyand’s hernia, presence of the appendix within an inguinal hernial sac, is a rare condition. We report a case of a 68-year-old
woman who presented during the COVID-19 pandemic with an acute right groin pain due to a tender incarcerated inguinal
hernia. Cross-sectional imaging confirmed an Amyand’s hernia. She proceeded to open appendectomy via the inguinal canal
and primary suture repair of her inguinal hernia. Patient was discharged the following day. Surgical management of Amyand’s
hernia varies depending on the resources, clinical findings and personal experience. In our opinion and experience, open
hernia reduction, appendectomy and primary tissue repair repairs the most effective and appropriate approach especially
during the COVID-19 pandemic.

INTRODUCTION CASE REPORT

Amyand’s hernia is defined as presence of the appendix within
an inguinal hernia sac. This condition was first described in
1735 by Claudius Amyand, who operated on an 11-year-old boy
with an incarcerated inguinal hernia containing a perforated
appendix [1].
It is a rare condition and accounts for <1% of all inguinal
hernias. Acute appendicitis within an Amyand’s hernia occurs
in 10%. It predominantly occurs on the right side and is more
common in children and men [2, 3].
To our knowledge, <200 cases have been described in the
literature so far, and this is the first case reported in literature
that was managed during the COVID-19 pandemic. Several surgi-
cal approaches have been described; however, for a strangulated
appendix within right inguinal hernia sac, we propose an open
inguinal approach, appendectomy and primary suture repair
of the inguinal hernia as the most effective and appropriate
approach especially during COVID-19 pandemic.
A 68-year-old woman presented to the emergency department
with 1-day history of an acute onset right groin pain and a tender
swelling. She had a past medical history of osteoporosis and
hypertension and was on alendronic acid and ramipril regularly.
Otherwise, she was fit and well with no significant past surgical
history. On clinical examination she had a tender incarcerated
right inguinal hernia, but no signs of systemic illness or sepsis
or COVID-19-related symptoms.
Her vital signs were normal, and she was afebrile. Her ini-
tial laboratory tests were normal including white cell count of
8.3 × 109 /l, C-reactive protein of 4 mg/l and lactate of 0.9 mmol/l.
She proceeded to computed tomography (CT) of her chest,
abdomen and pelvis, which demonstrated acute appendicitis
within a right, direct inguinal hernia (Amyand’s hernia) with no
features of perforation, bowel obstruction or collections (Fig. 1).
There were no signs of COVID-19 on the chest CT. Her COVID
viral swab was also negative.

Received: January 23, 2021. Revised: March 29, 2021. Accepted: April 1, 2021
Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2021.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/),
which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

1
 2 Z. Afzal and R. O’Neill
Figure 1: CT scan images of a 68-year-old woman who presented with acutely inflamed appendix within a right inguinal hernia sac (Amyand’s hernia) during COVID-10
pandemic.
Figure 2: Intraoperative pictures of a 68-year-old woman who presented with acutely inflamed appendix within a right inguinal hernia sac (Amyand’s hernia) during
COVID-10 pandemic: (A) Preoperative examination finding of right-sided incarcerated inguinal hernia. (B, C) Strangulated acute appendicitis. (D) Surgical specimen
post-appendectomy.
She proceeded to surgery via an open inguinal approach.
Intraoperative findings included a tight necked direct inguinal
hernia containing strangulated distal appendix. The hernia sac
contained haemoserous fluid only. An open appendicectomy
was performed transfixing the appendiceal stump with 2/0
Ethicon Vicryl Suture. Although a mesh repair was considered,
it was felt the risk of subsequent infection was too high, and a
Bassini darn suture repair was performed with 1 Ethilon Nylon
Suture; the external oblique aponeurosis was closed with 2/0
Ethicon prolene (Fig. 2).
The patient made an uneventful post-operative recovery and
was discharged home the following day with 5 days of oral
antibiotics. There were no signs of hernia recurrence after 3-
month follow-up.
DISCUSSION
To our knowledge, this is the first reported case of Amyand’s her-
nia managed during the COVID-19 pandemic. This rare hernia
typically presents with groin pain and swelling and should be
distinguished from a femoral or standard inguinal hernia. The
appendix can be completed normal, inflamed, incarcerated or
perforated [4]. Since all are indications for operative repair, the
diagnosis is often made intraoperatively, although in many cases
preoperative CT scanning can guide the operative approach or
help determine operative risk in the case of concurrent COVID-
19 infection [5–7].
Most surgeons would traditionally advocate appendectomy
in the case of Amyand’s hernia, even if the appendix is nor-
mal, although this could be questioned in the light of recent
data on the immunological function of the appendix. A fur-
ther area of controversy is the use of mesh for hernia repair
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in a clean-contaminated procedure, and our preference in this
case was to avoid mesh due to the risk of infection. Current
guidelines advocate a laparoscopic approach for elective groin
hernia repair in a woman, although in the acute setting with the
likelihood of bowel resection open surgery is often still preferred.
Laparoscopic repair has been reported for Amyand’s hernia [3,
8], although a further level of complexity was added due to the
COVID-19 pandemic where national guidance suggested avoid-
ing laparoscopic surgery. On this basis we proceeded with open
surgery.
Losanoff and Basson described a systematic approach
towards the management of Amyand’s hernia based on the
appendix, which they classified from Type 1–4 (1 normal
appendix, 2 uncomplicated appendicitis, 3 acute perforated
appendicitis with peritonitis, 4 acute appendicitis with con-
comitant disease). For type 1, they recommended hernia
reduction and mesh repair with or without appendectomy. For
type 2, appendectomy, hernia repair without mesh. For type
3, appendectomy via midline laparotomy and hernia repair
without mesh. Type 4 should be managed according to the under-
lying pathology [9]. In this case we followed these pragmatic
recommendations.
CONCLUSION
Amyand’s hernia is an uncommon condition. The majority of
cases that presenting with acute appendicitis require appendec-
tomy. The use of mesh in the repair remains controversial, but
we advocate following the central principle that mesh should be
avoided in a potentially contaminated field.
Several approaches towards surgical repair have been
described in the literature; however, for a strangulated appendix

within right inguinal hernia sac, we propose an open hernia
reduction, appendectomy and primary tissue repair repairs as
the most effective and appropriate approach especially during 4.
COVID-19 pandemic.
5.
CONFLICT OF INTEREST STATEMENT
None declared. 6.
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